Acute Respiratory Distress Syndrome – National Guideline – Nepal

The development of the National Guideline for Acute Respiratory Distress Syndrome (ARDS) 2021 results from continuous collaboration between technical experts from various
specialties.

This guideline being the first of its kind will not only provide a uniform protocol for diagnosing and managing ARDS but will also help in the capacity building of health workers of various levels.

This will eventually strengthen our country’s health system like to immensely thank the Mohp Government of Nepal, the technical working group, and WHO Nepal for their technical support in making this possible.

Forewords: Introduction: Acute Respiratory Distress Syndrome Guideline

The COVID-19 pandemic has affected various aspects of human life and put enormous
pressure on the healthcare system and health workers. While most COVID-19 patients
either have mild symptoms or are asymptomatic, a few may develop Acute Respiratory Distress Syndrome (ARDS), which can be life-threatening.

ARDS carries a high mortality rate and should be identified at an early stage. It is thus important to be aware of how to diagnose and effectively manage such conditions.

There have been various onsite and virtual training of health care workers across the country on the management of critically ill patients with COVID-19 disease provided by the Ministry of Health and Population (MoHP) with World Health Organization (WHO) support.

This includes Essential Critical Care Training (ECCT), Pediatric Essential Critical Care Training (PECCT), and Infection Prevention and Control focusing on COVID-19 along with the development of management guidelines for clinicians.

As the COVID-19 pandemic continues, cases that develop ARDS will likewise continue to be
observed. It is therefore important to have a technical guideline for ARDS that guides our
health workers in providing the appropriate clinical care. To develop this essential document, MoHP formed a technical working group with experts from different professional societies

involved in COVID-19 patient management with WHO Nepal support. This technical work-
ing group, led by the COVID-19 Unified Central Hospital, Bir Hospital, included intensivists, pulmonologists, critical care nurses, rehabilitation, and public health experts.

The document is based on standard clinical management guidelines and includes the latest, evidence-based updates on COVID-19 clinical management available globally compiled by WHO.

This is the first of its kind which guides proper diagnosis and management of ARDS
in Nepal, including oxygen therapy and handling critical patients in high dependency and
intensive care units.

The National Guideline on Acute Respiratory Distress Syndrome will bring uniformity in early diagnosis, evaluation, and treatment of critical patients with ARDS in Nepal. It is a privilege to support MoHP in its development which will assist health workers in saving lives.

COVID-19 and ARDS

The global pandemic of severe acute respiratory syndrome-corona virus-2 (SARS-CoV-2) has emerged as a threat to humankind, challenging the healthcare system and public health strategies worldwide with Nepal being no exception.

As of November 2021, the COVID-19 pandemic has resulted in over 240 million cases and over 5 million confirmed deaths worldwide. Since the first case of COVID-19 in Nepal, there have been 8,13,433 cases with 11,427 deaths and 7,92,832 recoveries till 2nd November 2021.

Mortality resulting from SARS-CoV-2 infection occurs mainly through the SARS-CoV-2-induced ARDS. It is estimated that 85% of COVID-19 patients admitted to ICU meet the criteria of Berlin’s definition of ARDS.

Elevated inflammatory cytokines (IL-6, IL-1β, and TNF-α) together with impaired interferon responses, SARS-CoV-2 induced endothelial cell injury, and thrombosis in pulmonary microcirculation results in severe pneumonia and ARDS in COVID-19.

However clinical heterogeneity exists in COVID-19 ARDS. Gattinoni and colleagues
have highlighted the heterogeneity of COVID-19 ARDS and proposed the two primary phenotypes of COVID-19 ARDS: type L (low lung elastance, pulmonary ventilation/perfusion ratio, lung weight, and low recruitability) and type H (high lung elastance, right-to-left shunt, lung weight, and high recruitability), with type H being more consistent with typical severe ARDS.

Patients with COVID-19 ARDS may present early with type L and progress into type H due to worsening of disease severity along with patient self-inflicted lung injury.

The clinical course of COVID-19 ARDS follows typically one of the following three patterns: acute respiratory failure requiring immediate mechanical ventilation (type H), indolent clinical course with only moderate work of breathing (type L, or most often a biphasic course with initial indolent course followed by rapid deterioration occurring over 5-7 days.

COVID-19 ARDS appears to have poor outcomes compared with ARDS from other causes or non-COVID ARDS. Overall mortality in COVID-19 ARDS ranged between 26% and 61.5%. Among COVID-19 ARDS patients who require mechanical ventilation, the mortality is even worse and can range from 65.7% to 94%.

Section A -General

Introduction……………………………………………………………………………………………………………………..1

Definition…………………………………………………………………………………………………………………………..1

Epidemiology……………………………………………………………………………………………………………………2

Etiology / Risk Factors of ARDS……………………………………………………………………………………3

Pathogenesis of ARDS…………………………………………………………………………………………………..3

COVID-19 and ARDS……………………………………………………………………………………………………..4

Clinical Features of ARDS……………………………………………………………………………………………..4

Diagnostic Workup of a patient with ARDS……………………………………………………………..5

Determining the Cause of ARDS………………………………………………………………………………….6

SECTION B-Management

Respiratory Support………………………………………………………………………………………………………6

1.1 Oxygen Therapy……………………………………………………………………………………………………………6

1.2 Awake Self-pruning……………………………………………………………………………………………………..8

1.3 High Flow Nasal Cannula (HFNC)……………………………………………………………………………..9

1.4 Ventilatory Management………………………………………………………………………………………….11

1.4.1 Basics of Mechanical Ventilation…………………………………………………………………………11

1.4.2 Protocol for Use of Neuromuscular Blocking Agents (NMBA):………………………19

1.4.3 Lung Protective Ventilation…………………………………………………………………………………..20

1.4.4 Prone Position Ventilation……………………………………………………………………………………..22

1.4.5 Troubleshooting………………………………………………………………………………………………………24

1.4.6 Newer Modes…………………………………………………………………………………………………………..30

1.4.7 Liberation from Mechanical Ventilation………………………………………………………………31

1.4.8 Non-invasive Positive Pressure Ventilation (NIPPV)……………………………………….36

Rescue Therapy…………………………………………………………………………………………………………….37

Contributors for Acute Respiratory Distress Syndrome – National Guideline

1. Dr. Prajowl Shrestha, Coordinator and Deputy Director, COVID-19 Unified
   Central Hospital, Bir Hospital
2. Dr. Pawan Jung Rayamajhi, Director, CSD
3. Prof. Dr. Subhash Prasad Acharya, Intensivist, IOM, TUTH
4. Dr. Ashesh Dhungana, Pulmonologist and Critical Care Physician, NAMS,
   Bir Hospital
5. Dr. Navindra Raj Bista, Anesthesiologist, IOM, TUTH
6. Ms. Prabha Gautam, Critical Care Nurse, IOM, TUTH
7. Mr. Regan Shakya, Assistant Professor, Physiotherapy Program, KUMS
8. Dr. Hem Raj Paneru, Intensivist, IOM, TUTH
9. Dr. Basanta Gauli, Intensivist, Chitwan Medical College, Bharatpur
10. Ms. Nisha Bhandari, Critical Care Nurse, Chitwan Medical College, Bharatpur
11. Dr. Allison Gocotano, WHO
12. Ms. Shirley McQuen Patterson, WHO
13. Dr. Subash Neupane, WHO
14. Prof. Dr. Shital Adhikari, WHO
15. Mr. Kamaraj Devapitchai, Consultant, WHO
16. Dr. Amit Kumar Singh, WHO
17. Dr. Deepshikha Rana, WHO
18. Dr. Irana Joshi, WHO

Acute Respiratory Distress Syndrome PDF online and download

Here is the pdf of this national guideline for acute respiratory distress syndrome.

Acute Respiratory Syndrome Guideline Download